Presented by :

Silvia P. Tarigan
Counsellor :
H. Tisna Sukarna, dr., SpA, MBA

PATIENT IDENTITY
Name

: M Rafif Lathif

Age

: 1 month old

Sex

: Male

Date of hospitalized

: January, 16th 2011

Date of examination

: January, 16th 2011

Father :
Name

: Mr. Beni H

Mother :
Name

: Mrs. Siti M

Age

:36 years old

Age

:35 years old

Education

: Senior High
School

Education

: Senior High
School

Occupation :Entrepreneur

Occupation

: Housewife

Address :
Sukamukti
RT 3 RW 5, Katapang
Bandung.

Address : Sukamukti RT 3
RW 5, Katapang Bandung.

 Heteroanamnesis

was given by his mother on

January, 16 th 2011

Chief

complaint: convulsion

History of present illness:

One day before admission to the hospital patient had
convulsion as many as 1 time for 2 minutes The convulsion
are not preceded by fever. During the convulsion, suddenly
became stiff and uprolling of the eyes for 1 minutes. He
had a generalised tonic-clonic convulsion. Before and after
the convulsion patient was conscious. Patients mother
denied any historical information of falling from a baby
box.
2 days before entering the hospital, patient
experienced vomiting in each breast-feeding time. Patient
has not ever cried again since the convulsion.

The big brother of patient had experience the

convulsion at the age of 6 months old but was preceded
by fever. Patients mother stated that when the patient
was 1 week old, the baby was ikterik and it has still
happened until today. The patients mother also said
that the baby had not been given Vitamin K injection
when the baby was born

Urine: the color, volume, and frequency was normal and no

pain when urinate.

Defecation : the color, consistency, and frequency was

normal

Medical Effort: 1 day ago went to the midwife and got

some medicine.

Past Medical History: the patient never had sick like this
before.

History of family illness: The big brother of patient had

experience the convulsion at the age of 6 months old but
was preceded by fever

Birth History
The patient is the 3rd child from 3 children. No stillbirth
and no abortus.

Birth : aterm, spontaneous, directly cry and helped by a

midwife.

Birth weight : 3500 grams. Birth length : 52 cm

Physical and Intelligence Development

Turn over
: Sitting down
: Standing up
: Talking
: Walking
:-

 Immunization
Booster Vaccination
Vaccine

Recommended
Vaccination

Basic Vaccination

BCG

HiB

none

Polio

MMR

none

DPT

Hep A

none

Hep B

Varicella

none

Measles

Typhim/typha

: none

Influenzae

: none

Nutrition and Feeding

Breastmilk
Past Illnesses
Cough
Family history :
Convulsion

General appearance
Condition
Consciousness
Activity and position
General condition

: severe sickness
: somnolen
: no force position
: weak

Vital signs
Pulse

: 143 times a minute, regular, equal, strong

Respiration

: 36 times a minute, thoracoabdominal type

Temperature : 35,7 C, aksiler

Measuring
Weight
: 4,9 kg
Height
: 65 cm

(113,95 % standard Weight/Age )

(119,04 % standard Height/Age )

Nutrition status
Rumple Leede

: (standard Weight/Height )
: (-)

SYSTEMATIC EXAMINATION
4.1. Skin
: rash (-), pale (+), icteric (+), turgor was
immediately returns to normal position

Head
Hair : black, disseminated, not easy to yanked out
Fontanel : tense
Eyes : conjunctiva anemic +/+, conjungtiva hyperemic -/-,
sclera icteric +/+, pupil anisokor (diameter pupil sinistra >
dextra), light reflex : -/ Nose
: nostril breathing+/+, secret -/-, epistaxis -/ Lips
: wet, cyanosis +
Mouth
: moist mucosa
Gums
: no bleeding, no hyperemic
Palate
: no disparity
Tongue
: coated tongue -, hyperemic -, tremor ,
Kopliks spot
Pharynx and tonsil : hyperemic -, T1=T1

Neck
Nuchal rigidity
: (-)
Lymph node
: not palpable
Thorax
Lungs
Inspection
: shape and movement was simetric, right was equal
to left, retractions supraclavicle +

Palpation
: vocal fremitus right was equal to left
Auscultation : vesicular breath sound +/+, ronchi -/-,
wheezing -/Heart
Inspections : ictus cordis was not seen
Palpations : ictus cordis was palpable at ICS 4 linea
midclavicularis sinistra

Percussions
: border on top ICS 2 linea
parasternalis sinistra, border on left ICS 4 linea
midclavicularis sinistra, border on right ICS 3 linea
sternalis dextra
Auscultations
: heart sounds regular, shuffle

Abdomen :
Inspections : flat
Auscultations : bowel sound (+)
Percussions : tympanic, Traubes space : tympanic
Palpations
: , liver 4 cm below arch costarum,
tenderness (-), skins turgor was immediately returns to its
normal position.
Liver and spleen inpalpable

Genital
: male, normal
Anus & Rectal: no disparity
Extremities : no disparity
Upper : left: active, right : active
Lower : left: active, right: active
Joint : no disparity
Muscle : hypertrophy -, atrophy Neurological Examination
Reflex
: physiological -/-, pathological +/+

On January 16,2011

Hb : 9,3 gr / dl
Ht: 28,0%
Leu: 11700 / m3
Tc: 578000/m3
GDS : 94 mg/dl
Bilirubin total : 13,91 mg/dl
Bilirubin direk : 2,64 mg/dl
Bilirubin indirek: 11,2 mg/ dl

On January 17,, 2011

Hb : 10,5 mg/dl
Ht : 32,6 %
Leu : 8620/ m3
Tc : 517000/m3
Na : 124 mEq/L
K : 4,6 mEq/L
Ureum : 16 mEq/L
PT : 11.5 second
aPTT : 30,4 second
Fibrinogen : 396 mg/dl

22

CT- scan
On 16 January,2011
Trail:
Frontotemporoparietal left subdural haemorrhage is the
cause of the shifted midline to the left by 1, 29 cm; and
the constriction of the left lateral ventricle. There also
appears the hemorrhage of intracerebral in areas right-side
frontotemporoparietal.

1 month old boy, with 4,9 kg body weight, 60m body

height, nutritional status (standard Weight/Height) came
to Immanuel Hospital because convulsion.
One day before admission to the hospital patient had
convulsion as many as 1 time for 2 minutes The convulsion
are not preceded by fever. During the convulsion, suddenly
became stiff and uprolling of the eyes for 1 minutes. He
had a generalised tonic-clonic convulsion. Before and after
the convulsion patient was conscious. Patients mother
denied any historical information of falling from a baby
box.
2 days before entering the hospital, patient
experienced vomiting in each breast-feeding time. Patient
has not ever cried again since the convulsion.

The big brother of patient had experience the

convulsion at the age of 6 months old but was preceded
by fever. Patients mother stated that when the patient
was 1 week old, the baby was ikterik and it has still
happened until today. The patients mother also said
that the baby had not been given Vitamin K injection
when the baby was born

Urine: the color, volume, and frequency was normal and no

pain when urinate.

Defecation : the color, consistency, and frequency was

normal

Medical Effort: 1 day ago went to the midwife and got

some medicine.

Past Medical History: the patient never had sick like this
before.

History of family illness: The big brother of patient had

experience the convulsion at the age of 6 months old but
was preceded by fever.

Immunization profile: the patient havent receive all basic

immunization.

Nutrition status

: (standard Weight/Height)

General appearance
Condition
Consciousness
Activity and position
General condition

: severe sickness
: somnolen
: no force position
: weak

Vital signs
Pulse

: 143 times a minute, regular, equal, strong

Respiration

: 36 times a minute, thoracoabdominal type

Temperature : 35,7 C, aksiler

Skin : rash (-), pale (+), icteric (+), turgor was

immediately returns to normal position

Head
Eyes : conjungtiva anemic +/+, sklera ikteric +/+, light
reflex : -/-, pupil anisokor ; diameter pupil sinistra> dextra
Fontanel
: tense
Nose
:nostril breathing+/+, secret -/-,
Mouth
: moist mucosa
Tongue
: Kopliks spot
Pharynx and tonsil : hyperemic -, T1=T1

Neck
Lymph node : not palpable
Thorax
Lungs
retractions supraclavicle +
vesicular breath sound +/+, ronchi -/-, wheezing -/-

Abdomen
Liver 4 cm below arch costarum

On January 16,2011

Hb : 9,3 gr / dl
Ht: 28,0%
Leu: 11700 / m3
Tc: 578000/m3
GDS : 94 mg/dl
Bilirubin total : 13,91 mg/dl
Bilirubin direk : 2,64 mg/dl
Bilirubin indirek: 11,2 mg/ dl

On January 17,, 2011

Hb : 10,5 mg/dl
Ht : 32,6 %
Leu : 8620/ m3
Tc : 517000/m3
Na : 124 mEq/L
K : 4,6 mEq/L
Ureum : 16 mEq/L
PT : 11.5 second
aPTT : 30,4 second
Fibrinogen : 396 mg/dl

32

CT- scan
On 16 January,2011
Trail:
Frontotemporoparietal left subdural haemorrhage is the
cause of the shifted midline to the left by 1, 29 cm; and
the constriction of the left lateral ventricle. There also
appears the hemorrhage of intracerebral in areas right-side
frontotemporoparietal.

Differential Diagnosis : Intracranial hemorrhage

Increased in Intracranial Pressure
Sepsis neonatorum
Working diagnosis

:Intracranial hemorrhage (subdural

and intraserebral hemorrhage)

Additional diagnosis

: Anemia, Hiperbilirubin neonatus,

hiperglikemia neonatorum

Serial Lumbar Punctures

Blood gas analysis
CT Scan
USG

 Quo

ad vitam
Quo ad functionam

: dubia ad bonam
: dubia ad bonam

Non Medicamentous
Treated in the PICU
Fluid : Ringer Lactat 500cc / 24 hour
O2 nasal 2Lpm
Fasting
Medicamentous
Amoxicillin : 3 x 500 mg iv
Kalmethason : 2 x 1 mg iv
Garamicine : 2 x10 mg iv
Mannitol : 3 x 10 cc, drip
Vit K : 2 x 1 mg, IM every day ( during 5 day)
Diazepam : 1 mg prn
PRC 50 cc during 3 hours
FFP 50 cc during 3 hours

Jan 16 th, 2011

Subjective:
Groan (+)
Convulsion (+)
Pale (+)
Objective:
Sklera ikteric (+/+), pupil
anisokor ( diameter pupil
sinistra> dextra)
Skin : pale (+), ikteric (+)
Fontanel : tense
Bradipnoe RR:12 x/m
SpO2 : 97 %
Nastril breath +/+,
retraction +/+

Therapy

02 nasal 2 lpm

Fluid : RL 500cc /24h

Fasting

Amoxillin 3 x 500 mg iv

Garamisin 2 x 100 mg iv

Diazepam 1 mg

Mannitol 3 x 10 cc, drip

Vit K : 1 mg IM, during 5 days

Transfussion PRC 50 cc
during 3 hours

Plan to transfussion FFP 50

cc during 3 hours

Jan 17th, 2011

Subjective:
Groan (-)
Convulsion (+)
Cry (+)
Objective:
Sklera ikteric (+/+), pupil
anisokor ( diameter pupil
sinistra> dextra)
Skin : ikteric (+)
Fontanel : tense
SpO2 : 100 %
Nastril breath -/-,
retraction -/-

Plan:
02 nasal 2 lpm
Diet : fasting
IVF : Aminofuchsin ped
100cc/hour, D5 %+ valium
15 mg 400 cc/24 hour
Transfusi WB 50 cc
Amoxillin 3 x 500 mg iv
Garamisin 2 x 100 mg iv
Mannitol 3 x 10 cc, drip
Vit K : 1 mg IM, during 5
days

Jan 18th, 2011

Subjective:
Convulsion (+)

Objective:
Sklera ikteric (+/+), pupil
anisokor ( diameter pupil
sinistra> dextra)
Skin : ikteric (+)
Fontanel : tense
SpO2 : 100 %,spontaneus
breathing
Nastril breath -/-,
retraction -/-

Plan:

Craniotomy

Diet : fasting

IVF : Aminofuchsin ped

100cc/hour, D5 % 400 cc/24
hour

Amoxillin 3 x 500 mg iv

Garamisin 2 x 100 mg iv

Kalmethason 2x1 mg

Mannitol 3 x 10 cc, drip

Phenitoin 2x 25 mg

Diazepam 1 mg prn

Vit K : 1 mg IM

Jan 19th, 2011

Subjective:
Convulsion (+)
Eyelash (+)
General condition :
improve

Objective:
Sklera ikteric (+/+), pupil
isokor , light reflex +/+
Skin : ikteric (+)
Fontanel : soft
spontaneus breathing
Nastril breath -/-,
retraction -/-

Plan :

Diet : D5 % 6 x 10 cc

KaEN 1 B 100 cc

Aminofucsin 100 cc

Amoxillin 3 x 500 mg iv

Garamisin 2 x 100 mg iv

Kalmethason 2x1 mg

Phenitoin 2x 25 mg

Vit K : 1 mg IM

Novalgin 4x 50 mg

Valium 1mg prn

The Diagnosis of based Intracranial Hemorrhage In the Newborn

on :
Anamnesis :

Patient was 1 month year old

Convulsion wasnt preceded by fever

never cry again since seizures

vomitting

ikteric

had not been given Vitamin K injection when the baby was born.

The big brother of patient had experience the convulsion at the age of 6
months old

Physical Diagnostic

Skin : pale (+), ikteric (+)

Fontanel : Tense

Eyes : conjungtiva anemic +/+, sklera ikteric +/+,

light reflex : -/-, pupil anisokor ; diameter pupil sinistra> dextra

Nose : Nostril breathing (+)

Thorax : retractions supraclavicle +

CT Scan :
subdural and intraserebral haemorrhage

Vitamin K is one of the essential vitamins.

The letter K in vitamin K actually comes from the word

"Koagulations", that means coagulation or clotting.

Without vitamin K, blood would be unable to clot.

Deficiencies in vitamin K lead to clotting disorders, bruising, and
other blood disorders.

a coagulation disturbance in newborns due to vitamin K

deficiency. As a consequence of vitamin K deficiency there is an
impaired production of coagulation factors II, VII, IX, X, by the
liver

Causes
Newborns are relatively vitamin K deficient for a variety of
reasons. They have low vitamin K stores at birth, vitamin K
passes the placenta poorly, the levels of vitamin K in breast milk
are low and the gut flora has not yet been developed (vitamin K
is normally produced by bacteria in the intestines).

Brain tumors

Bleeding (hemorrhage) or blood clots (hematomas) from injuries

(subdural hematoma or epidural hematomas)

Weaknesses in blood vessels (cerebral aneurysms)

Damage to tissues covering the brain (dura)

Pockets of infection in the brain (brain abscesses)

Epilepsy

Definition

Bleeding in the cranial cavity and its contents in infants from

birth until age 4 weeks.

Intracranial Hemorrhage includes epidural, subdural,

subarachnoid, intra serebral/parenkim dan intraventrikuler
hemorrhage

Epidemiology

from 5 to 15 %, with a mortality of from 40 to 50 %

low birth weight infants, weighing less than 1500 g)

Etiology
The chief cause is trauma

Breech extraction, in which rapid or forceful delivery of the

after-coming head produces the injury.

Precipitate labors, where there is sudden compression of the

head.

Very difficult or prolonged labors, where there is excessive

molding of the head with injury.

Instrumental deliveries

Cause not trauma

Prematurity of the infant

Grade I: hemorrhage limited to the germinal matrix

(subependymal hemorrhage)

Grade II: hemorrhage which has extended into the ventricular

system but without dilation of the lateral ventricles

Grade III: hemorrhage extending into the ventricular system with

the blood resulting in ventricular dilatation

Grade IV: hemorrhage which extends into the brain tissue (this
grade is also referred to as PVH and associated with
intraparenchymal echodensity (IPE) by some

Epidural hemorrhage (extradural hemorrhage) which occur

between the durameter and the skull, is caused by trauma It
may result from laceration of an artery, most commonly the
middle meningeal artery dangerous type of injury because
the bleed is from a high-pressure system and deadly increases in
intracranial pressure can result rapidly

Subdural hemorrhage results from tearing of the bridging veins

in the subdural space between the dura and arachnoid mater

Subarachnoid hemorrhage which occur between the arachnoid

and pia meningeal layers, can result either from trauma or from
ruptures of aneurysms or arteriovenous malformations

Intraventrikuler hemorrhage

hypoxia

vasodilatation blood vessel of the brain and venous congestion

increase blood flow

elevated pressure of the brain blood

Easily Ruptur

Onset of symptoms of intracerebral hemorrhage is usually during

daytime activity, with progressive :

Alteration in level of consciousness (approximately 50%)

Nausea and vomiting (approximately 40-50%)

Headache (approximately 40%)

Seizures

Focal neurological deficits

Cephalic cry

Snake like flicking of the tongue

Expiratory grunting

Physical exam:

unconscious individual should quickly assess the adequacy of

the airway, breathing, pulse, and blood pressure before beginning
a more detailed neurological and physical exam.

The latter includes an evaluation of level of consciousness,

pupil response and vital signs, motor function, reflexes, and
memory.

Serial Lumbar Punctures

Blood gas analysis
CT Scan
USG

Treated in the incubator that allows continuous observation and

O2 delivery

It should be observed carefully: body temperature, degree of

consciousness, pupil size and reaction, motor activity, respiratory
frequency, heart frequency, pulse rate and diuresis.

Keeping the airway to remain free.The baby lies on his side

Vitamin K and blood transfusions may be considered.

Valium / luminal if convulsion, valium dose from 0.3 to 0, 5 mg /

kgBB

Corticosteroids such as dexamethasone 0.5 to 1 mg/kgBB/24

hours that have good effect against hypoxia and brain edema

Antibiotics can be given to prevent secondary infection

Lumbar puncture to reduce intracranial pressure, bleeding,

prevent obstruction likuor flow and reduce the effects of
irritation on the surface of the cortex

Emergency surgery Craniotomy

Staging I, II : mild

Staging III, IV : severe

Intracranial hemorrhage is a serious medical emergency because

the build up of blood within the skull can lead to increases in
intracranial pressure

Severe increases in intracranial pressure can cause potentially

deadly brain herniationin